Exhibit 1 Mother's Worksheet.pdf

This document is a Mother's Worksheet for Child's Birth, designed for collecting comprehensive demographic and personal information to create a birth certificate. The form is aligned with federal and state requirements, including provisions from 42 USC 406(f) and is intended to be used by health and medical researchers to study and improve maternal and newborn health. The worksheet requires detailed information about the mother, including her legal name, social security number, residence, education, race, Hispanic origin, and pregnancy-related details.

The form also captures additional information such as the mother's height, pre-pregnancy weight, cigarette smoking habits during pregnancy, marital status, and options for including the father's information. There are sections for recording the father's legal name, birth details, education level, Hispanic origin, and race. The document includes a permission section to provide Social Security Administration information and requires certification from the informant that the provided information is true and correct according to Nebraska Revised State Statute 71-649.